694 Pinner Road

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence. We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s outcomes were not always consistently good.

The service was in breach of legal regulation in relation to consent to care and treatment.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them. Some relatives told us they received updates from the service about their loved one’s health and social care needs; however, some relatives told us change in needs were not always communicated with them. The service did not always assess what was in the best interests of all people living at the care home, nor did they always include people and relatives in the decision-making process.

The service did not always plan and deliver person-centred care and treatment. Care records we reviewed and feedback from some staff indicated that care was being tailored to meet the needs of some people who live in the service, but not all. This approach did not ensure equitable and personalised care for each person.

The service did not always work well across teams and services to support people. Feedback from staff we spoke with indicated a disparity in partnership working and in the safe and effective management of some people’s care needs. Some staff we spoke with told us feedback and recommendations from partner originations was not always acted upon and listened to by senior leadership. Additionally, some staff told us that their perspectives were not always heard or valued by senior leadership. We raised this with the provider, and they informed us they have policies and procedures in place to ensure that staff are supported to speak openly and treated fairly. Senior leadership told us they would ensure the team are aware and would work on building trust, to enable staff to feel comfortable and confident raising concerns.

The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to reduce their future needs for care and support. For example, the fridge, freezer and some cupboards in the communal kitchen were locked, which limited people’s independence and access to food and drink.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The service did not monitor progress against action plans to improve the quality and safety of the service and take appropriate action without delay where progress was not achieved as expected. This placed people at risk of harm.

Staff had received Mental Capacity Act 20025 (MCA) and Deprivation of Liberty Safeguards (DoLS) training. However, the service was not always clear to people about their rights around consent and did not always respect their rights when delivering care and treatment.

Feedback from staff and commissioners indicated that some people were being restricted unlawfully, because these restrictions were not authorised as part of their DoLS.

The fridge, freezer and some cupboards in the communal kitchen were locked, which limited people’s independence and access to food and drink. We reviewed all the mental capacity assessments for people living at the service, there were none in place for people regarding locked cupboards, fridge and freezer. Additionally, we observed a person being restricted to an area of the home on the day of assessment. There was no record of a best interests decision or that the restriction was as a result of a condition of their DoLS authorisation, to explain the restrictive practice imposed. Mental capacity assessments for all people were generic and not person specific. The rational and the specific decision as to why a mental capacity assessment and best interest decision were required were not recorded. This meant that the provider was not always working according to the MCA principles to ensure people’s rights were always safeguarded.